Celebrating 10 years of care in your community.
Message from THE DIRECTORS Welcome to our tenth anniversary edition of the Report to the Community. This is a significant period in our history. This year we reflect on providing ten years of care in the community, but also focus on the road ahead through the evolution of primary care and our pursuit of building and sustaining a community of medical homes. In 2006, a handful of physicians envisioned a primary care network (PCN) in the Westhills and downtown areas. Over 60 physicians joined the CWC PCN that first year and our organization started operations with programs and services for physicians and their patients. Ten years later, we have helped over 200,000 patients through our patient care teams, attached thousands of patients to a physician, as well as providing after-hours access through a clinic that provides care seven-days-a-week. These are significant milestones. Today, our PCN has over 440 physicians providing comprehensive, community-based primary care to more than 329,000 patients in 129 medical practice locations. With Calgary’s growing and aging population, physicians need help meeting the demands of caring for patients with chronic disease. In addition, doctors are dealing with the complexities of caring for the elderly in the community. Some of the top health issues that Calgary doctors continue to face today include diabetes, mental health, weight management, hypertension and
cholesterol management. The CWC PCN provides programs and services to assist physicians with these major health issues. Patient Care Teams (PCTs) are a core service provided to physicians. They include nurses that specialize in chronic disease management, maternity, geriatrics and behavioural health consultants that provide mental health assistance in the clinic. In addition, social workers assist patients with navigating the system. Finally, patient care coordinators assist with outreach and they proactively contact a physician’s patients for screening and follow-up. We invite you to read more in this report about patients we see everyday and about the doctors that helped form this PCN and their vision for patient care. We also thank the community for their support of primary care networks. Finally, we encourage you to connect with your family physician. If you need a doctor, we can help you find one. We want you to think of the primary care network as part of the neighbourhood.
Dan Doll, Executive Director
Dr. Jane Ballantine, Medical Director
Our vision has never been stronger.
Message from THE BOARD OF DIRECTORS On behalf of the Board of Directors, I am pleased to share highlights from our past year and also reflect on ten years of service to patients, physicians and the community. When the Calgary West Central Primary Care Network (CWC PCN) began in 2006, the goal of enhancing patient care by supporting local family physicians was at the heart of our plans – this remains true today. Ten years later, as we review our collective work, we have much to be proud of. We also have much to do as we prepare for the next ten years, with a major focus on the evolution of primary care. Our vision has never been stronger. In this past year, we have scaled several programs in order to service more doctors and to meet the future needs of care in the community. The Primary Care Centre (PCC) located in Westbrook and Patient Care Teams (PCTs) remain cornerstone programs. Last year, 39,841 patients were seen by health care professionals working alongside
CWC PCN P.G. Co. BOARD OF DIRECTORS family physicians in the community. In addition, over 8,000 patients were seen as part of our seven-daya-week, same-day access service at the PCC. Over 5,000 patients were also cared for at the Tsuut’ina clinic. When these accomplishments are placed against the context of our historic timeline outlined in this report, you see major growth in service to patients. Our programs and services also remain aligned with a patient-centric medical home – or a practice where people feel most comfortable receiving their ongoing care. The medical home is at the centre of our recently revised mission and vision. I would like to thank staff, our member physicians, patients and the community for being a part of the our journey and wish you good health.
Dr. Brendan Vaughan, Board Chair
From left to right: Dr. Scott Beach, Board Director; Dr. Scott Forsyth, Board Director; Dr. Maya Grover, Board Director; Dr. Margot McLean, Vice Chair; Dr. Jacqueline Swirsky, Board Director; Dr. Phillip van der Merwe, Board Director; Dr. Brendan Vaughan, President & Board Chair; Dr. Elka Walsh, Public Board Member; Dr. Wildermar (Waldi) Wilken, Secretary-Treasurer; Dr. Elisabeth (Betsy) Woolner, Board Director.
Alberta is a leader in primary health care reform in this country. ~ Dr. Phillip van der Merwe
Dr. Phillip van der Merwe, Family Physician | Dr. Waldi Wilken, Family Physician | Dr. Chris Gorrie, Family Physician
Reflecting on 10 years WITH OUR FOUNDERS “Alberta is a leader in primary health care reform in this country. We still have a way to go, but we are doing something pretty fantastic here.” Team-based care gives the patient the ability to access the right person for the right problem at pretty much the right time. I don’t always have the expertise or time to counsel somebody about their condition. If it’s a mental health issue, then it’s better to have a psychologist do that. When we’re in a team practice, we can surround our patients with the appropriate care. “It’s quite phenomenal,” concludes Dr. van der Merwe.
The CWC PCN would like to acknowledge our first Medical Director, Dr. Fred Moriarty. Thank you for your service to patients and the Primary Care Network.
When reflecting on ten years, Dr. Waldi Wilken recalls, “We thought we’d just do a small PCN for the Westhills area. It was basically me and Atilla Nadori, Jeff Pivnick, Phillip van der Merwe and Chris Gorrie - the four of us decided we would also include downtown in our group. It snowballed from there and we ended up with the first application being around 60 doctors, but it just kept growing.” Now the CWC PCN is one of the largest in Alberta. “The general perception was to get physicians healthy with ample support, whether we had nursing support or whatever the physicians needed to make them feel they could cope with their workload. The patient benefited from all the services, but the main drive at that stage was to secure a healthy physician and a healthy family practice,” Dr. Wilken adds.
Dr. Chris Gorrie is a long-term family doctor who helped set up the Calgary West Central PCN. At first, he and a small team met in a colleague’s basement, then they moved to a rented room in the Westhills Recreational Centre for meetings. Gorrie recalls trying to get skeptical doctors to join the primary care model. “We were like telephone solicitors,” he says - we had a heck of a time to get people to join us, but join us they did. From beating the bushes in 2006, Calgary West Central PCN now has 440 doctors, 329,000 patients and 120 support staff, all from a handful of guys eating sandwiches in a colleague’s family room with ideas to help patients and doctors.”
“In the future, I think the PCN is going to play a big role in letting physicians act as a cohesive group verses individual physicians.”
DR. PHILLIP VAN DER MERWE Board Director
Calgary West Central PCN
DR. WALDI WILKEN Board Director
Calgary West Central PCN
DR. CHRIS GORRIE Assistant Medical Director Calgary West Central PCN
~ Dr. Jeff Pivnick
Dr. John Coppola, Family Physician | Dr. Jeff Pivnick, Family Physician
It’s in our
Reflecting on 10 years WITH OUR FOUNDERS
“I think the greatest impact the PCN has on physicians is engaging and bringing family doctors together through our own network – I have made a lot of good connections with other physicians and these are people who I still enjoy connecting and collaborating with today,” Dr. Coppola says.
When Dr. Jeff Pivnick thinks back on his early involvement in helping to establish the CWC PCN, one of the driving visions at that time still holds true today. “Collectively, we can do more together as a group than independently.” “Doctors were skeptical at first about how this primary care initiative would affect them and it was around the same time that electronic medical records were emerging. A lot of evolutionary forces were at play for the family physician,” says Dr. Pivnick. The idea of building a network of family doctors that could bring additional resources like teams and programs was really about the collective strength and Pivnick believes that nobody really imagined the full scope of benefits of working on larger issues. Ten years later, Dr. Pivnick says, “Primary Care Networks will continue to play an important role in the evolution of family practice in the future.”
DR. JOHN COPPOLA Family Physician
Calgary West Central PCN
DR. JEFF PIVNICK Family Physician Calgary Foothills PCN
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Dr. Coppola was in practice for over 30 years. “Over my career, I’ve seen medical charts go from being on recipe cards and paper and in the last 10 to 15 years, to electronic medical records. The next step is for PCN to help doctors use this rich source of data for proactive management of patients, healthcare service delivery planning, research, quality improvement and the professional development of healthcare providers.”
Patient Story
Jason Cheever, Patient | Margot Bergevin, Primary Care Nurse | Dr. Indu Khosla, Family Physician
It’s in our
Jason Cheever’s JOURNEY TO WEIGHT LOSS
Primary Care Networks (PCNs) provide people with long-term, team-based care anchored by a family doctor and a medical home for every stage of life. The CWC PCN provides family physicians with patient care teams including nurses, behavioural health consultants and patient care coordination. Jason Cheever, 57 years old, lost 60 pounds with the guidance and support of his physician and nurse. “It’s a lot easier having somebody helping you,” Jason Cheever says. “It was surprisingly much easier than I thought it would be,” says Cheever. He dropped to 255 pounds from 317 by following a healthy eating plan. “I never thought about calories. Eating healthier food was enough for me to lose all this weight and exercising decreased my hunger.”
It all began in 2012, when Dr. Indu Khosla, Cheever’s doctor, diagnosed arthritis in his knee and high blood pressure. She recommended using the PCN to help eat healthy, be more active and lose weight. Margot Bergevin, a CWC PCN nurse advised him on healthy eating, hydration and active living and discussed his actions and goals with him. “It’s good motivation,” Cheever says. He now walks 45 minutes a day, six days a week, outdoors or on a treadmill and is aiming to weigh 215 pounds. “It’s something I probably could have done on my own, but it’s a lot easier having somebody helping you,” Cheever concludes.
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It’s something I probably could have done on my own, but it’s a lot easier having somebody helping you.
Years of care
Patient Story
Dr. Scott Beach, Family Physician | Jill McWilliam, Primary Care Nurse | Ralph Hodgins, Patient
Ralph Hodgins’ Journey A TEAM APPROACH TO CARE If there was a pill for willpower, that’s all I would need quite frankly, but there isn’t such a thing, so I know what I have to do. It seems only fitting that Ralph Hodgins’ journey with diabetes began at the Calgary International Airport. It was while working there as a white hat volunteer greeting and assisting travellers that the affable retired elementary school principal began to notice a tingling and burning sensation in his feet. “I tried different shoes and socks but nothing worked,” he shrugged. A visit to his doctor revealed that he had neuropathy, a long-term complication of diabetes that causes damage to the nerves leading to the arms, hands, legs and feet. “I honestly didn’t know that I had diabetes,” he said. “I wasn’t running to the bathroom, I didn’t have excessive thirst…I just had sore feet.” Diagnosed with type 2 diabetes, Ralph was placed on Metformin, an oral diabetes medicine to help control his blood sugar levels. However, he struggled with his weight and his blood sugars levels, tracked as ‘A1C,’ remained a challenge. In 2005 his doctor retired and Ralph began his new long-standing relationship with CWC PCN family physician, Dr. Scott Beach.
“At that time his measurement outcomes for diabetes were not to target,“ explained Dr. Beach. “We looked at his medications and tried to reinforce more discipline in his diet and more regularity to his exercise, but it was difficult. I couldn’t spend enough time with him to maintain momentum and his progress was slow.” The addition of Jill McWilliam, a PCN nurse, to Dr. Beach’s office marked a turning point in Ralph’s care. A chronic disease management nurse, she met with him regularly to track his progress, improve monitoring and encourage healthier lifestyle choices. He was also started on insulin and referred to a pharmacist for further support. “When I first met Ralph his biggest challenge was weight management and lifestyle,” explained Jill. “He would indulge in dessert every night and eat based on convenience. He’d come back from a holiday or trip with a sheepish look because he’d gained weight or because his A1C levels were too high.” To help reinforce his lifestyle, Ralph was invited to join other patients in sessions hosted by Jill and Dr. Beach monthly at the CWC PCN’s Primary Care Centre. These peer support sessions included an introduction to diabetes, healthy eating, physical activity and so on.
“They were good, particularly for somebody who’s newly diagnosed. I think the real value is that you all learn from one another,” said Ralph. Ultimately, it was a lesson well taken. Sixty pounds lighter, Ralph now does aquasize four times a week, spends ten minutes on a treadmill after meals and is mindful of what he eats. “Once he made that realization he really started walking the talk,” Jill enthused. “At the beginning he was sheepish-Ralph who would come in with a high A1C, but now he speaks with confidence and he is really focused on his health.” Dr. Scott Beach continues to meet with Ralph every four months and sees a difference in his long-time patient. “His targets are certainly much better,” explains Dr. Beach. “He’s more consistent in his blood sugar measurements, his neuropathy is feeling better and his body mass has diminished.” And Ralph is committed to walking the talk. “If there was a pill for willpower, that’s all I would need quite frankly,” he smiles. “But there isn’t such a thing, so I know what I have to do. And when I get really good readings, I know that I’ve been successful.”
Our Programs & Services
Mike Bell, Behavioural Health Consultant | Sylvia Huber, One of our original Primary Care Nurses
It’s in our
Think of us as part of
YOUR NEIGHBOURHOOD
We support this community of medical homes by providing programs and services that enhance the care that patients receive through their family doctor. These services include Patient Care Teams (PCTs), who work with family physicians with an emphasis on chronic disease management, health promotion, disease and injury prevention and improved care of medically complex and chronically ill patients. Patient Care Teams consist of behavioural health consultants, nurses, patient care coordinators and social workers.
Behavioural Health Consultants (BHCs)
BHCs work at physician clinics and see individuals, couples and families for a wide-range of issues including depression, anxiety, stress, relationship issues and sleep concerns.
Nurses (LPN, GNC, RN)
Our nurses work collaboratively with family physicians and other members of the PCTs to create comprehensive care plans for patients. Nurses provide education, resources, community and PCN referrals, as well as motivational interviewing to help increase the overall health and well-being of patients. Nursing team members include primary care nurses, geriatric nurse consultants, licensed practical nurses and maternity care nurses.
Patient Care Coordinators (PCCs)
Patient Care Coordinators (PCCs) help doctors gain a better understanding of their patients’ needs by arranging well-organized patient visits and coordinating appointments, including recommended screening, disease prevention and health management.
Social Workers
Social workers connect with patients as often as required to determine their needs and refer them to appropriate resources for ongoing assistance. Social workers are based out of the CWC Primary Care Centre at Westbrook and sessions are conducted in the clinic or at the patient’s home. In addition to Patient Care Teams, other CWC PCN services that support the medical home include: • E nhanced access to the CWC Primary Care Centre with a seven-day-a-week, same day appointment service for patients in immediate need who are referred by their PCN family physician or Health Link. This referral service provides an alternative to the walk-in system or a visit to the emergency room. • A ccess to a physician through the CWC Primary Care Centre for patients who do not yet have a family doctor. • H elping to ensure you have a doctor and that you maintain a strong connection with them.
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For 10 years the CWC PCN has been working in partnership with member physicians to help build and sustain a community of patient-centred medical homes.
Our Programs & Services
Arlene Cordero, Patient Care Coordinator | Patricia Hinds, Social Worker
It’s in our
Calgary West Central
PRIMARY CARE CENTRE
The CWC PCC operates as an extension of a patient’s medical home by offering seven-day-aweek, same day access through an appointment service. Patients in immediate need can be referred by their PCN family physician’s practice. This service is available 365 days-a-year and includes weekends and holidays. Patients unable to see their PCN member physician receive an appointment at our centrally located clinic and their physician receives a record of their care. This referral service provides an alternative to the walk-in system or an unnecessary visit to the emergency room. Patients can also call Health Link at 811 to receive an appointment if their physician is unavailable.
The CWC PCC also provides a transition service where patients can receive care while they are waiting to be connected with a family doctor. It is an appointment-based clinic that sees patients on a interim basis. People in the Calgary area can register at www.calgaryareadocs.com to find a physician. In addition, seniors with complex medical issues can be referred by their physician to the PCC’s Geriatric Assessment & Support (GAS) program for a comprehensive assessment. The team meets with elderly patients who typically have multiple health problems and may have limited access to resources. This program helps patients access medical and community services, provides support for personal needs and identifies gaps in care. Last year 508 patients were seen by the GAS program and 132 patients were seen by its Geriatric Psychiatrists.
Primary Care Clinic in the
TSUUT’INA HEALTH CENTRE The Primary Care Clinic in the Tsuut’ina Health Centre has been providing Tsuut’ina Nation members and their families with high-quality, team-based health care for nearly a decade. The Tsuut’ina Nation borders Calgary’s southwestern city limits and the clinic serves to enhance access for a substantial population that otherwise might be challenged to find primary care.
PCN physicians, nurses and office assistants staff an on-reserve medical clinic providing primary care services, as well as screening and comprehensive care for chronic diseases such as diabetes, high blood pressure, obesity and many other conditions. There is also a comprehensive women’s health program, dedicated to screening, prevention and early intervention for a range of women’s health issues.
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The CWC Primary Care Centre (CWC PCC) at Westbrook is conveniently located near the Westbrook LRT station and is operated by the Calgary West Central Primary Care Network (CWC PCN).
Our membership: 129 MEDICAL PRACTICE LOCATIONS Advanced Primary Care
CUPS Community Health Centre
Associate Clinic #330
Deerfoot Meadows Medical Clinic
Associate Clinic #340
Dr. A. Pandya’s Medical Clinic
Associate Clinic #362
Dr. Bruce Jespersen’s Office
Associate Clinic #363
Dr. Catherine McKenna Nutrition & Weight Management
Associate Clinic #364
Dr. Keith Laatsch’s Office
Associate Clinic #370
Dr. Lesley Coulter’s Office
Beltline Medical Clinic
Dr. Lynne Murfin’s Office
Beverly Glenmore Centre
Dr. Mish and Dr. Noiles’ Office
Braeside Medical Centre
Dr. Paul James Tkalych’s Office
Braeside on 24th Medical Clinic
Dr. Pyarali Mitha’s Office
Breast Cancer Supportive Care
Dr. Richard Lam’s Office
Bridgeland Medical Clinic
Dr. Robert Cole’s Office
Calgary Foot & Ulcer Care Clinic
Dr. Robert Herget’s Office (Associate Clinic #366)
Calgary Weight Management Centre
Dr. Stajen Warness’ Office
Calgary West Medical Centre
Dr. Susan Poon’s Office
Canyon Meadows Clinic
Dr. Wilmot’s Office
Carewest Dr. Vernon Fanning Centre
Drs. Louie & Tse’s Office
Carewest Sarcee Hospice
Drs. McLean, Harvey & van der Merwe’s Office
Centennial Wellness
Drs. Nichol, Pereles & Searles’ Office
Chinook Mall Medical Clinic
Drs. Woolner, Chan & Yuen’s Office
Chinook Medical Centre
Eaton Centre Medical Clinic
Chiron Medical Clinic
Elbow River Healing Lodge
Coach Hill Medical Clinic
Fairmount Medical Clinic
Copeman Healthcare Centre
Foothills Hospital
Cornerstone Medical Centre
Glamorgan Medical Clinic
Crescent Medical Centre
Glenbrook Medical Clinic A
Glenbrook Medical Clinic B
Mission Medical Clinic
Glenmore Family Physicians
Mount Royal Medicentre
Glenmore Landing Vein Clinic
Mount Royal University Health Services
Glenwood Medical Centre
My Calgary Doctor
Good Health Medical Centre
Nuwest Medical Centre
Grasslands Medical Clinic
Oak Bay Medical Centre
Heritage Family Medical Centre
Primary Care Centre - GAS
Heritage Hill Medicentre
Prime Care Medical
Humana Medical Clinic
Revolution Medical Clinic
Hygieia Medical Clinic
Rhythm Health
Infinity Pediatrics
Richmond Road Family Medical Centre
INLIV Full Circle Health
Richmond Square Medical Centre
Innovations Health Clinic
Rockyview General Hospital
Intramed Medical Centre
Rockyview Heritage Clinic
Kaleidoscope Pediatric Consultants
Rockyview Maternity & Family Practice Group
Killarney Medical Clinic
Rockyview Medical Clinic
Kingswood Medical Centre
Saluté Family Medicine
Lakeview Family Doctors
SMC Addiction Medicine
Lakeview Medical Clinic
SMC Family Medicine
LifeMark Physiotherapy
SMC Sexual & Reproductive Health
Living Beyoutifully
South Health Campus
Matrix MSK
South Trail Medicentre
Mayfair Medical Clinic
Southland Medical Clinic
MCI The Doctor’s Office at 130th Ave
Southland Sport Medicine
MCI The Doctor’s Office at Midtown
Southport Family Practice
Meadows Maternity and Family Practice
Southwood Care Centre
Medical Express
Southwood Medical Centre
Springview Medical Clinic Strathcona Family Medicine Centre Sunnyhill Pediatric Clinic The Alex - Seniors’ Health The Alex - Youth Health The Alex Community Health Centre Tom Baker Cancer Centre Total Skincare Centre Tsuut’ina Health Centre University Health Services Clinic Valley Ridge Medical Clinic Vantage Medical Vesia - Alberta Bladder Centre V-Medi Spa West Springs Medical Clinic Westbrook Medical Clinic Westglen Medical Centre Westhills Medicentre Westside Medical Clinic Woodbine Medical Centre Zamin Medical Centre
Thank you to our physicians, patients and staff who shared their stories. Please share a copy with a friend.
info@cwcpcn.com
www.cwcpcn.com